Embolization with the Amplatzer Vascular Plug in TIPS Patients

Vessel embolization can be a valuable adjunct procedure in transjugular intrahepatic portosystemic shunt (TIPS). During the creation of a TIPS, embolization of portal vein collaterals supplying esophageal varices may lower the risk of secondary rebleeding. And after creation of a TIPS, closure of the TIPS itself may be indicated if the resulting hepatic encephalopathy severely impairs mental functioning. The Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN) is well suited for embolization of large-diameter vessels and has been employed in a variety of vascular lesions including congenital arteriovenous shunts. Here we describe the use of the AVP in the context of TIPS to embolize portal vein collaterals (n = 8) or to occlude the TIPS (n = 2).     

Intrahepatic Portosystemic Venous Shunt: Successful Embolization Using the Amplatzer Vascular Plug II

A 67-year-old woman presented with memory impairment and behavioral changes. Brain MRI indicated hepatic encephalopathy. Abdominal CT scans revealed an intrahepatic portosystemic venous shunt that consisted of two shunt tracts to the aneurysmal sac that communicated directly with the right hepatic vein. The large tract was successfully occluded by embolization using the newly available AMPLATZERTM Vascular Plug II and the small tract was occluded by using coils. The patient''s symptoms disappeared after shunt closure and she remained free of recurrence at the 3-month follow-up evaluation.     

Utility of the Amplatzer Vascular Plug in Splenic Artery Embolization: A Comparison Study with Conventional Coil Technique

Purpose  

To retrospectively evaluate the role of the Amplatzer Vascular Plug (AVP) in proximal splenic artery embolization (SAE) compared with coils.     

A New Device for Vascular Embolization: Report on Case of Two Pulmonary Arteriovenous Fistulas Embolization Using the Amplatzer Vascular Plug

A pulmonary arteriovenous fistula (PAVF) is a rare vascular malformation commonly treated by embolization with coils or balloons to prevent the risk of several serious complications such as cerebral embolism and brain abscess. A 32-year-old female with two PAVFs and neurological ischemic manifestations has been successfully treated by transcatheter embolization of both fistulas using a new device (Amplatzer Vascular Plug). This self-expanding cylindrical nitinol mesh cage with high radial strength allows a chance of relocation until properly positioned. It is preferred to coils or balloons because a large caliber of feeding artery implied high risk of uncontrollable distal embolization. There appear to be no reports in the literature concerning use of this device, which could represent a useful innovative tool in embolotherapies, especially in large vascular areas.     

Successful Embolization of a Spontaneous Mesocaval Shunt Using the Amplatzer Vascular Plug II

A 48-year-old man with alcoholic liver cirrhosis and hepatic encephalopathy was found to have a large, spontaneous mesocaval shunt. The shunt was successfully occluded with the use of an Amplatzer Vascular Plug. To our knowledge, this is the first report of the use of this device to embolize a mesocaval shunt involving the superior mesenteric vein.     

Applications of the Amplatzer Vascular Plug 4

The purpose of this study was to present our initial experience with the Amplatzer? Vascular Plug (AVP) 4 in various arterial environments. This material was designed for the embolization of peripheral small vessels using a diagnostic catheter. Herein, the following three procedures using the AVP 4 were described: hemodialysis fistula occlusion as a treatment for the steal phenomenon, gastroduodenal artery embolization prior to liver radioembolization, and vertebral artery embolization for the treatment of subclavian artery pseudoaneurysm and arteriovenous fistula. All of the treated vessels were successfully occluded, and the devices remained in the original locations and configurations during the follow-up period. When compared with the previous generation of vascular plugs, the AVP 4 allows faster and safer procedures with less radiation exposure to the patients and angiography team.     

Transhepatic Preoperative Portal Vein Embolization Using the Amplatzer Vascular Plug: Report of Four Cases

The Amplatzer Vascular Plug (AVP) is a device originally intended for arterial and venous embolization in peripheral vessels. From December 2004 to March 2007 we implanted a total of 8 AVPs in the portal venous system in our institution for preoperative portal vein embolization in 4 patients (55–71 years) prior to right hemihepatectomy. AVP implantation was successful in all patients. Total occlusion of the embolized portal vein branches was achieved in all patients. There were no major complications associated with the embolization.     

Percutaneous Transcatheter Embolization of a Large Pulmonary Arteriovenous Fistula with an Amplatzer Vascular Plug

Percutaneous transcatheter embolization has become the treatment of choice for pulmonary arteriovenous fistulas (PAVFs), in most cases replacing surgical intervention. However, while "classic" devices, such as intravascular coils and detachable balloons, have proved to be successful for interventional occlusions of small or medium-sized PAVFs, they are not ideal in larger fistulas because of the risk for embolization to the systemic circulation. We describe the case of a 61-year-old woman with a symptomatic huge solitary pulmonary arteriovenous fistula (4.5 cm in diameter), occupying part of the lung in the lower right lobe with two feeding arteries (10 and 4 mm in diameter, respectively), who underwent successful transcatheter closure with an Amplatzer Vascular Plug, a new device designed for the occlusion of vascular abnormalities.     

Applications of the Amplatzer Vascular Plug to various vascular lesions

The Amplatzer^® Vascular Plug (AVP) can be used to embolize medium-to-large high-flow vessels in various locations. Between 2009 and 2012, 41 AVPs (device size, 6–22 mm in diameter) were used to achieve occlusion in 31 patients (24 males, seven females) aged 9–92 years (mean age, 54.5 years). The locations and indications for embolotherapy were as follows: internal iliac artery embolization before stent-graft repair for aorto-iliac (n=6) and common iliac artery (n=3) aneurysms, subclavian artery embolization before stent-graft repair for thoracic aorta (n=3) and arcus aorta (n=1) aneurysms, brachiocephalic trunk embolization before stent-graft repair for a thoracic aorta aneurysm (n=1), embolization of aneurysms and pseudoaneurysms (n=5), embolization for carotid blow-out syndrome (n=3), closure of arteriovenous fistula (n=8), and closure of a portosystemic fistula (n=1). Of the 41 AVPs, 30 were AVP 2 and 11 were AVP 4. The mean follow-up duration was 4.7 months (range, 1–24 months). During follow-up, there was one migration, one insufficient embolization, and one recanalization. The remaining vascular lesions were successfully excluded from the circulation. The AVP, which can be used in a wide spectrum of pathologies, is easy to use and causes few complications. This essay presents our experience with the AVP.The Amplatzer^® Vascular Plug (AVP, AGA Medical Corp., Golden Valley, Minnesota, USA) is a good alternative to other embolic materials (1). The AVP has many advantages over embolic materials such as coils or glue. It is retractable, and it can be repositioned. Use of the AVP has cost advantages over other embolic materials. It can be used safely in trauma patients or in patients before endovascular aortic repair (EVAR). It ensures permanent occlusion, and its migration risk is less than for coils. The results of embolization with the AVP have been excellent (2), and no contraindications for its use have been reported (3). All four types of AVP have two components: a vascular plug and a delivery wire. The plugs have radiopaque platinum marker bands at both ends (4). The AVP 2 contains a more densely woven nitinol mesh and minimizes migration and recanalization (5). The AVP 4 is used mostly in small, tortuous vessels (6). The AVP is made of self-expanding material, and it returns to its original shape after release from the catheter. It has a long delivery cable, is preloaded in a loader, and is delivered through guiding catheters ranging from 5 to 8 F in size. The AVP is released by rotating the delivery cable counterclockwise.Thirty-one patients (24 males, seven females) aged 9–92 years (mean age, 54.5 years), who underwent percutaneous occlusion with the AVP at our hospital between 2009 and 2012, were evaluated retrospectively. Patients with any pathology involving AVP use for embolization were included in this study. Patients in whom only other embolic materials were used were excluded. The study was approved by the Institutional Review Board and consent was obtained from the patients before the procedures. Most patients underwent general anesthesia. A transfemoral arterial or venous approach was used in most patients. In the patient with a portosystemic fistula, a transjugular approach was used. The procedures were performed under heparinization only in patients with a pulmonary arteriovenous fistula (AVF) or thoracic aorta aneurysm.In 24 of the 31 patients, we used only the AVP as the embolic material. In the remaining seven patients, we used the AVP with coils. In six of the 31 patients, more than one AVP was used. In total, 41 AVPs (30 AVP 2, 11 AVP 4), 6–22 mm in diameter, were used. The diameter of the AVP was selected to be 30%–50% larger than that of the targeted location in each patient. Computed tomography (CT) angiography was used most commonly for follow-up imaging (mean follow-up duration, 4.7 months; range, 1–24 months). This pictorial essay presents our experience using the AVP in various locations as material to embolize medium-to-large vessels with high flow.     

Inferior Mesenteric Artery Embolization Before Endovascular Aortic Aneurysm Repair Using Amplatzer Vascular Plug Type 4

Purpose

This study was designed to evaluate the efficacy and safety of Amplatzer Vascular Plug type 4 (AVP-4) for embolization of the inferior mesenteric artery (IMA) before endovascular aneurysm repair (EVAR) of the abdominal aorta to prevent endoleaks.

Methods

A single-center retrospective review of 31 patients who underwent IMA embolizations before EVAR using the AVP-4 was performed. We analyzed the insertion and detachment procedure, the technical success, and the final position of the plug. Technical success was defined as complete occlusion of the IMA. To compare the incidence of IMA-related type II endoleaks in patients with and without preoperative IMA embolization, we additionally reviewed the course of 43 patients with a preoperatively patent IMA who underwent no IMA embolization.

Results

Plugs with a diameter of 5, 6, and 8 mm were used in 5 (16.1 %), 21 (67.7 %), and 5 (16.1 %) patients, respectively (50–100 % oversizing). In 29 of 31 patients (93.5 %), we observed complete occlusion of the IMA within 10 min (mean 5.1 min). Precise placement of the plug in the proximal segment of the IMA without occlusion of the first IMA branches was achievable in all patients. The distance between the AVP-4 and the first branches was on average 12 (range 2–57) mm. Preoperative IMA embolization with AVP-4 significantly reduced the incidence of complex IMA-lumbar type II endoleaks after EVAR (0/31 vs. 11/43; p = 0.002).

Conclusions

The AVP-4 is a safe, feasible, and technically effective embolization device for IMA embolization before EVAR.     

Amplatzer Vascular Plug: expanding the applications spectrum

The Amplatzer Vascular Plug is a new embolization device which has been used in different vascular anomalies, especially by cardiologists in the cardiac and pulmonary circulations. It is underused by interventional radiologists. We used this device in three different vascular conditions, which we present here.     

Initial Clinical Experience Using the Amplatzer Vascular Plug

Background and purpose The Amplatzer Vascular Plug (AVP) is a self-expanding nitinol wire mesh vascular embolization device derived from the Amplatz septal occluder. We assessed the results of vascular embolization obtained using the AVP. Methods A retrospective review was carried out of 23 consecutive cases of vascular embolization using the AVP in a variety of different clinical settings. The AVP was chosen to have a diameter approximately 30–50% greater than the target vessel. The device was delivered via an appropriately sized guide catheter and was released when satisfactorily positioned. Additional embolic agents were used in some cases. Results All target vessels were successfully occluded with no device malpositioning or malfunction. In 14 (61%) patients the AVP was the sole embolic material. In the remaining patients additional agents were used, particularly in preoperative embolization of highly vascular renal tumors. The AVP does not cause instantaneous thrombosis and in high-flow situations thrombosis typically takes up to 15 min. Conclusion The AVP is a safe, effective embolization device that provides a useful adjunct to the therapeutic armamentarium. It is particularly suited to the treatment of short high-flow vessels where coil migration and catheter dislodgment might occur. In the majority of cases no additional embolic agents are necessary but it may take up to 15 min for complete thrombosis to occur.     

Use of Amplatzer Vascular Plug to Treat a Biliary Cutaneous Fistula

Several substances have been used in an attempt to sclerose biliary ducts associated with persistent biliary-cutaneous fistula (BCF). The AMPLATZER Vascular Plug (AVP; AGA Medical, USA) system is a recently developed endovascular occlusion device, introduced as an alternative to permanent embolic materials (metallic coils or acrylic glue), in the occlusion of large and medium-calibre arteries and veins. We report a successful use of the AVP to embolize BCF, developed after the removal of an internal-external biliary drainage.     

Utility of Amplatzer Vascular Plug with Preoperative Common Hepatic Artery Embolization for Distal Pancreatectomy with En Bloc Celiac Axis Resection

CardioVascular and Interventional Radiology - To evaluate the feasibility and safety of the Amplatzer vascular plug (AVP) for preoperative common hepatic embolization (CHA) before distal...